The use of Suprathel(®) in deep dermal burns: first results of a prospective study

Introduction

While autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on dl-lactid acid (Suprathel^®) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn.

Methods

We recruited 18 patients with a median age of 45 years (range: 25–83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively.

Results

Fifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p = 0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel^® on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel^® areas.

Conclusion

Suprathel^® represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel^® can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel^® can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.     

Sustainable effectiveness of single‐treatment autologous fat grafting in adherent scars

Following severe injury, not just the skin but also the subcutis may be destroyed. Consequently, the developing scar can become adherent to underlying structures. Reconstruction of the subcutis can be achieved by autologous fat grafting. Our aim was to evaluate the long‐term scar outcome after single‐treatment autologous fat grafting using a comprehensive scar evaluation protocol. Scar assessment was performed preoperatively in 40 patients. A 12‐month follow‐up assessment was performed in 36 patients, using the Cutometer, the Patient and Observer Scar Assessment Scale, and DSM II ColorMeter. The Cutometer parameters elasticity and maximal extension improved with 28 and 22% (both p < 0.001), respectively. Nearly all scores of the scar assessment scale decreased significantly, which corresponds to improved scar quality. In addition, the mean melanin score was ameliorated over time. Thus, we demonstrated the sustainable effectiveness of single‐treatment autologous fat grafting in adherent scars, indicated by improved pliability, and overall scar quality.     

Patient‐reported scar quality of adults after burn injuries: A five‐year multicenter follow‐up study

Scar formation is an important adverse consequence of burns. How patients appraise their scar quality is often studied shortly after sustaining the injury, but information in the long‐term is scarce. Our aim was, therefore, to evaluate long‐term patient‐reported quality of burn scars. Adults with a burn center admission of ≥1 day between August 2011 and September 2012 were invited to complete a questionnaire on long‐term consequences of burns. We enriched this sample with patients with severe burns (>20% total body surface area [TBSA] burned or TBSA full thickness >5%) treated between January 2010 and March 2013. Self‐reported scar quality was assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Patients completed this scale for their—in their opinion—most severe scar ≥5 years after burns. This study included 251 patients with a mean %TBSA burned of 10%. The vast majority (91.4%) reported at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and 78.9% of the patients’ overall opinion was that their scar deviated from normal skin. Patients with severe burns had higher POSAS scores, representing worse scar quality, than patients with mild/intermediate burns, except for color, which was high in both groups. A longer hospital stay predicted reduced scar quality (both mean POSAS and mean overall opinion of the scar) in multivariate analyses. In addition, female gender was also associated with a poorer overall opinion of the scar. In conclusion, this study provides new insights in long‐term scar quality. Scars differed from normal skin in a large part of the burn population more than 5 years after burns, especially in those with severe burns. Female gender is associated with a poorer patients’ overall opinion of their scar, which may be an indication of gender differences in perception of scar quality after burns.     

Long‐term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study

The laser Doppler imager is used in cases of indeterminate burn depth to accurately predict wound healing time at an early stage. The laser Doppler imager classifies burns into three estimated healing potentials as follows: high, <14 days; intermediate, 14–21 days; and low, >21 days. At this time, the relationship between these healing potentials and long‐term scar quality is unknown. The objective of this study was to determine the long‐term scar quality of burns with three distinct healing potentials. The secondary objectives were to compare treatment strategies in intermediate wounds, to study the effect of the timing of surgery on low healing potential wounds and to identify predictors of reduced scar quality. Hence, in a prospective cohort study, scar quality was determined in patients whose burns were assessed with laser Doppler imaging. Scar Quality was assessed with objective and subjective measurement tools, including overall scar quality (Patient and Observer Scar Assessment Scale) as a primary outcome and color and elasticity parameters. A total of 141 patients (>19 months postburn) with 216 scars were included. Wounds with high and intermediate healing potential did not significantly differ regarding scar quality. Wounds with a low healing potential had a significantly lower scar quality. Analysis of 76 surgically treated low healing potential wounds showed no significant differences in the primary outcome regarding the timing of surgery (≤14 days vs. >14). Predictors of reduced long‐term scar quality were darker skin type and multiple surgeries. In conclusion, scar quality was strongly related to the healing potential category. Scar quality was very similar in high and intermediate healing potential wounds. No positive effects were found on scar quality or on healing time in surgically treated wounds with intermediate healing potential, advocating a conservative approach. Further studies should focus on the optimal timing of surgery in low healing potential wounds.     

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

ObjectiveThe purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre.MethodA retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales.ResultsClearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury.ConclusionA steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.     

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BackgroundThe aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.MethodsThe translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.ResultsIn total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86–0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.ConclusionThe PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.     

Investigating the intra- and inter-rater reliability of a panel of subjective and objective burn scar measurement tools

BackgroundResearch into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools.MethodsThree independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires.ResultsThe inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons.ConclusionThe objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.     

Epidermal-cell-based therapy as an adjunct to healing second degree burns—A randomized controlled pilot study

BackgroundHealing of partial-thickness (2a and 2b) burns is notoriously unpredictable as far as healing time, scarring and (hypo)pigmentation is concerned. Epidermal blister grafting is an autologous grafting technique involving transfer of epidermal islands without dermal elements. Cellutome™ is an FDA-acknowledged epidermal harvesting device. This proof-of-concept study evaluates whether blister grafting of partial-thickness burns results in improved healing compared to standard acellular treatment.MethodsThis is a randomized controlled trial with 8 patients in which each patient received both treatments randomized to different burn sites. Healing was assessed at regular intervals. Twelve months after treatment, outcomes were measured with the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), photography, spectrometry, Semmes-Weinstein Filaments, cutometry and high-resolution ultrasound.ResultsAreas treated with epidermal blister grafting healed slightly faster than acellular treatment. Epidermal treatment yielded healing with less erythema, closer to that of surrounding normal skin (p = 0.0404). Donor sites were not visible and not measurably different than normal skin.ConclusionsResults favor cellular over acellular technique for the treatment of partial-thickness (2a and 2b) burns. Significant improvement in erythema implies a higher quality healing process. Further studies should look primarily at larger areas of treatment, and larger sample size.     

脱细胞异体真皮与自体瘢痕薄皮复合移植的临床应用

目的:为大面积深度烧伤后期继发瘢痕挛缩、功能障碍且皮源不足的患者寻求比较理想的治疗手段.方法:切开松解功能区孪缩的瘢痕组织,将脱细胞异体真皮与自体大张瘢痕薄皮复合移植覆盖创面,加压固定包扎.结果:5例患者12个创面中,除一个创面皮片部分坏死外,余均成活.术区平整、柔软,所植皮片挛缩轻,无瘢痕增生,功能恢复良好.结论:脱细胞异体真皮 自体瘢痕薄皮复合移植是目前修复大面积深度烧伤患者功能部位创面,实现功能重建的有效方法.     

Methods of burn treatment. Part II: Technical aspects]

The best treatment for burns and scalds depends on the depth of the skin necrosis. Epidermal and superficial dermal burn injuries (IIa) can heal spontaneously with conservative treatment without scar development, but deep dermal or full-thickness burns constitute an absolute indication for surgery. Full-thickness or split-thickness skin grafts are used for wound closure. In the case of extensive burn injuries allografts are used for temporary wound closure. In certain licensed laboratories autologous keratinocytes can be cultured for transplantation. In circumferential burn injuries affecting the extremities or the trunk the rigid eschar has to be incised to relieve the pressure behind it. Following a debridement conservative treatment of superficial dermal burns involving wound coverage with biosynthetic dressings or nanocristalline silver gauze dressings or use of special disinfecting ointments can be implemented.     

A critical analysis of measurements used to assess and manage scars

Scars evolve through a maturation stage during which it is necessary to adapt different treatments. To adapt treatments, it is necessary to assess various parameters linked to inflammation. To this end, clinical scar assessments are subjective though reliable, and validation is operator dependent. The Vancouver Scar Scale, Visual Analogic Scale, Patient and Observer Scar Assessment Scale, and the Manchester Scale assess different scar characteristics. These scales are interesting, depending on the type of scars, and are easy to use but subject to errors. To use clinical a scale, the raters must be trained. Parameters can also be precisely assessed by technical means, whereby they rate only one parameter, but are more accurate. Some scales are easy to use, have low cost, and can be used for clinical assessment. Others scales are more complex and expensive, and can be used in research or treatment evaluation.     

Behandlungskonzepte bei Verbrennungen

The best treatment for burns and scalds depends on the depth of the skin necrosis. Epidermal and superficial dermal burn injuries (IIa) can heal spontaneously with conservative treatment without scar development, but deep dermal or full-thickness burns constitute an absolute indication for surgery. Full-thickness or split-thickness skin grafts are used for wound closure. In the case of extensive burn injuries allografts are used for temporary wound closure. In certain licensed laboratories autologous keratinocytes can be cultured for transplantation. In circumferential burn injuries affecting the extremities or the trunk the rigid eschar has to be incised to relieve the pressure behind it. Following a debridement conservative treatment of superficial dermal burns involving wound coverage with biosynthetic dressings or nanocristalline silver gauze dressings or use of special disinfecting ointments can be implemented.     

Flaminal® versus Flamazine® in the treatment of partial thickness burns: A randomized controlled trial on clinical effectiveness and scar quality (FLAM study)

Although partial thickness burns are the most frequently reported burn injuries, there is no consensus on the optimal treatment. The objective of this study was to compare the clinical effectiveness and scar quality of Flaminal® Forte to silver sulfadiazine (Flamazine®) in the treatment of partial thickness burns. In this two‐arm open label multicenter randomized controlled trial, adult patients with acute partial thickness burns and an affected total body surface area of less than 30% were randomized between Flaminal® Forte and Flamazine® and followed for 12 months. Dressing changes in the Flamazine® group were performed daily, and in the Flaminal® group during the first 3 days post burn and thereafter every other day until complete wound healing or surgery. Forty‐one patients were randomly allocated to Flaminal® Forte and 48 patients to Flamazine®. The primary outcome was time to wound healing, which did not differ between the groups: median 18 days with Flaminal® Forte (range 8–49 days) versus 16 days with Flamazine® (range 7–48 days; p = 0.24). Regarding the secondary outcomes during hospital admission, there were no statistically significant differences between the groups concerning need for surgery, pain scores, pruritus, or pain‐related and anticipatory anxiety. More patients in the Flaminal® group developed wound colonization (78% versus 32%, p < 0.001), but the treatment groups did not differ regarding the incidence of local infections and use of systemic antibiotics. In terms of scar quality, no statistically significant differences between both treatment groups were found regarding subjective scar assessment (Patient and Observer Scar Assessment Scale (POSAS)), scar melanin and pigmentation (DermaSpectrometer®), and scar elasticity and maximal extension (Cutometer®) during 12 month postburn. In conclusion, time to wound healing did not differ, but the use of Flaminal® Forte seemed favorable because less dressing changes are needed which lowers the burden of wound care.     

Internet‐based survey on current practice for evaluation,prevention, and treatment of scars,hypertrophic scars,and keloids

No universally accepted standard for evaluation, prevention, and treatment of scars, hypertrophic scars, and keloids exists. Following development of a questionnaire, we performed a closed Web‐based survey among burn centers. Server‐based data collection was performed over 4 weeks and closed thereafter. The poll revealed emerging new treatment schemes, but the majority of participants adhered to evaluation (Patient and Observer Scar Assessment Scale, Matching Assessment of Scars and Photographs, Vancouver Scar Scale, two‐dimensional photography) and prevention (silicone gel sheets and compression garments) strategies that were in line with the currently available recommendations from the literature. We noted a low penetration for the use of objective evaluation tools in our poll and detected differences in surgical approaches to keloids. Based on the results of our survey and the power of currently available clinical recommendations, we expect future guidelines to gain more evidence‐based power, especially when more high‐quality clinical trials with objective evaluation support, clearly defined disease entities, and therapeutic outcome factors have become available.     

Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study

IntroductionFor extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury.MethodsA multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7–10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application.ResultsThirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time.DiscussionThese results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.     

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BackgroundSkin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.MethodsA prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.ResultsThis study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.ConclusionThis study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.     

Clinical effectiveness of dermal substitution in burns by topical negative pressure: A multicenter randomized controlled trial

Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four‐armed multicenter randomized controlled trial, a split‐skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full‐thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.     

Clinimetric properties of a translated and culturally adapted Norwegian version of the Patient and Observer Scar Assessment Scale for use in clinical practice and research

PurposeTo translate and culturally adapt the Patient and Observer Scar Assessment Scale, POSAS, to Norwegian and explore its test-retest, intra- and inter-tester reliability.MethodsPOSAS was translated into Norwegian following international guidelines in collaboration with an international translation bureau. Twenty-six adults and 24 children were recruited from a burns outpatient clinic. Three observer-categories: doctor, nurse and physiotherapist, assessed the patients’ scars and scored the Observer scale for estimating inter-tester reliability. Photos of the scars were taken and used to score the Observer scale a second time for examining intra-tester reliability. The patients or parents/next of kin rated their scar on the Patient scale at the clinic and after two days at home for examining test-retest reliability. Intraclass correlation (ICC) and Kappa were used for statistical analysis.ResultsA Norwegian version of POSAS (POSAS-NV) was developed. Inter-tester ICC of the Observer parameters varied between 0.203 and 0.728, and for the total sum score, ICC = 0.528 (0.280–0.708). Intra-tester ICC of the Observer scale ranged between 0.575 and 0.858. The Patient scale demonstrated high test–retest reliability.ConclusionsIntra-tester reliability of the Observer scale and test–retest reliability of the Patient scale of POSAS-NV were found satisfactory, but not inter-tester reliability of the Observer scale.     

Suprathel(®) causes less bleeding and scarring than Mepilex(®) Transfer in the treatment of donor sites of split-thickness skin grafts

Split-thickness skin grafts are routine in the treatment of deep dermal burns and various other wounds. Healing of the donor site of the graft has an impact on the total recovery of the patient. We conducted a prospective clinical study at Tampere University Hospital to compare the effect of two adhesive wound dressings, Suprathel(?) and Mepilex(?) Transfer. The donor sites of 22 split-thickness skin grafts were studied, each of which was covered with Suprathel(?) and Mepilex(?) Transfer dressings side by side. Significantly less pain and bleeding was associated with Suprathel(?) treatment compared with Mepilex(?) Transfer (p < 0.05). Suprathel(?) produced a better scar at the three months' follow-up as measured using the Vancouver Scar Scale (VSS). The results show that Suprathel(?) is a better dressing for the donor sites than Mepilex(?) Transfer.     

Long‐term follow‐up comparison of two different bi‐layer dermal substitutes in tissue regeneration: Clinical outcomes and histological findings

Double layer dermal substitute (DS) consist of a 3‐dimensional collagen structures and a superficial silicon layer that are positioned within the defect provide to promote tissue regeneration in skin wounds. DS often have unique physical characteristics due to differences in manufacturing techniques. The aim of this study is the clinical and histological comparison of Nevelia and Integra double layer DSs in patients with post‐traumatic injury wounds. Thirty patients with post‐traumatic wounds localised on the inferior limbs were randomised in 2 groups Nevelia or Integra, followed by autologous dermal epidermal graft (DEG). Clinical results were evaluated through the healing time; Manchester Scar Scale (MSS) and Visual Analog Scale (VAS) at 1, 2, and 3 weeks and after 1 and 3 years. Histological and immunohistochemical evaluation were performed at 0, 2, and 3 weeks. The difference in healing time between groups (P = .467, log‐rank test), pain and self‐estimation was not statistically significant after 35, 42, and 49 days and at 1‐year follow up. Histological data showed evident healing of wound after 2 weeks compared with preoperative with both DSs. At 3 weeks reepithelialisation and dermal regeneration were evident with both substitutes; however Nevelia showed early regenerative properties in terms of epidermal proliferation and dermal renewal compared with Integra. Nevelia showed also a more evident angiogenesis vs Integra evaluated as α‐SMA immunohistochemistry. Differences in the MSS score were statistically significant at 3 years follow up in favour of Nevelia group (P = .001). At long‐term follow up, Nevelia showed a better clinical outcome measured as MSS score vs Integra measured as MSS. Histological and immunohistochemistry data showed that Nevelia allows faster neoangiogenesis and tissue regeneration with neoformed tissue architecture closer to the physiology of the skin.